“Hey Nurse! You got to get me off this board!” Kerriann Dooley, RN BSN and Julia Smith, RN BSN University of Virginia Emergency Department, Charlottesville, VA ABSTRACT Purpose: To improve patient outcomes and determine the effectiveness of early backboard removal by the Registered Nurse (RN) among adult conscious patients who arrive in the Emergency Department (ED) with full spinal immobilization. Background: A review of the literature revealed long wait times for low acuity trauma patients arriving in full spinal immobilization before a physician assessment and removal of backboard. Complications of long wait times on backboards include skin breakdown, iatrogenic pain, respiratory compromise, decreased patient satisfaction and aspiration. Numerous hospitals successfully implemented protocols for RNs to initiate early backboard removal for these patients. Methods: Following review of current practice, policy, and literature, nurse residents proposed a policy to ED leadership, staff and hospital administration to lead an interdisciplinary team effort for practice change. Results: Hospital leadership approved the new policy for nurse driven removal of backboards which outlined an evidence-based procedure for proper removal of backboard by RN. Barriers identified for successful use of new policy include educating and supporting RNs to change practice. RN removing backboard with assistance of 3 staff members in ED OBJECTIVES 1. Discuss evidence that nurse mediated early backboard removal in an emergency department setting improves patient satisfaction and comfort without compromising spinal integrity. 2. Relate the importance of early trauma assessment by the RN to patient safety and other nurse sensitive quality indicators including skin breakdown and iatrogenic pain. 3. Describe mechanisms impacting skin damage as a result of sustained pressure on the firm surface of backboards and nursing interventions which mitigate skin damage. BACKGROUND Themes from the literature Long wait times Complications from backboards Decreased patient satisfaction Pressure-related skin breakdown Iatrogenic pain Anxiety Respiratory compromise Aspiration Financial implications related to hospital acquired skin breakdown and poor pain management Barriers identified for RN backboard removal practice change RNs believing not in their scope of practice Workload Education and support Communication with healthcare team National Recognition Support by Emergency Nurses Association Included in Trauma Nursing Core Curriculum (TNCC) Articles in Journal of Emergency Nursing (Bechard, 2012) Support by Consortium for Spinal Cord Medicine “In the Emergency Department, transfer the patient with a potential spinal injury as soon as possible off the backboard onto a firm, padded surface while maintaining spinal alignment” (2008) METHODS Review of Practice Nurse residents found no current policy for backboard removal in a level one trauma center Patients wait for physician assessment prior to backboard removal High acuity patients: MD and RN both receive emergency transport services (EMS) report and work together to get patient off backboard immediately. Low acuity patients: RN receives EMS report and triages patient; patient waits up to an hour for MD to assess patient and remove backboard. Patients often complain of pain and feeling anxious while lying on backboard. Policy Proposal Nurse residents created a policy to detail appropriate backboard removal with appropriate staff. Policy was presented to ED nurse manager, nurse educator, nursing director, medical director, 35 staff members at 2 staff meetings (day and night shift), as well as hospital adult critical care administrator, and 80 nurse residents and nurse managers at evidence based practice project presentation. RESULTS Effective September 2013 ED RNs can remove backboards for patients who arrive in full spinal immobilization as long as they meet certain inclusion criteria and do not meet any exclusion criteria. Inclusion Criteria: Patients who arrive in full spinal immobilization Age greater than 18 and less than 65 Low risk mechanism of injury (MOI) with low index of suspicion Exclusion Criteria: Pediatric and elderly patients Unconscious and/or unresponsive patients Glasgow Coma Scale less than 15 Intoxicated patients or patients with known drug use Dangerous or high risk mechanism of injury (MOI)* Distracting painful injury** Paresthesia or loss of movement/sensation to any extremity Airway compromise, significant shortness of breath or uncontrolled bleeding NEXT STEPS Overcoming barriers Interdisciplinary and multi-media approach to education Computer based learning (CBL) presentation and test Video demonstrating correct procedure for backboard removal by RN and 3 additional staff Electronic medical record documentation education ID badge cards with inclusion/ exclusion criteria listed Evaluation Follow up using education chain Survey to evaluate comfort with practice change Timeline February 24 : Assign CBL to all ED nursing staff March 3 – March 21 Huddling talking points Badge cards handed out Shift oriented learning opportunities (SOLO) Education chain follow up March 28 : CBL due March 31 : Go live with policy and practice June 1 : Survey sent to ED staff References Bechard, L., Harding, A. (2013). Registered nurse-initiated patient removal from backboards in the emergency department. Journal of Emergency Nursing, 39(1), 57-58. doi: 10.1016/j.jen. 2012.09.010 Clement, C. M., Stiell, I. G., Davies, B., O’Connor, A., Brehaut, J. C., Sheehan, P., Clavet, T., Leclair, C., MacKenzie, T., Beland, C. (2011). Perceived facilitators and barriers to clinical clearance of the cervical spine by emergency department nurses: A major step towards changing practice in the emergency department. International Emergency Nursing, 19(1), 44-52. doi: 10.1016/j.ienj. 2009.12.002 Consortium for Spinal Cord Medicine. (2008). Early acute management in adults with spinal cord injury: a clinical practice guideline for health care professionals. Journal of Spinal Cord Medicine, 31(4), 403-479 Meek, R., McGannon, D., Edwards, L. (2007). The safety of nurse clearance of the cervical spine using the National Emergency X- radiography Utliization Study low-risk criteria. Emergency Medicine Australasia, 19(4), 372-376. doi: 10.1111/j. 1742-6723.2007.00995.x *High risk MOI include but not limited to: **Distracting painful injury include but not limited to: Fall from height > 3 feet Long bone fracture Axial loading to head Thoracic or upper torso injury Motor vehicle collision (MVC) at speed > 60mph Long bone fracture MVC with rollover and/ or ejection Large burns Motorized recreational vehicle or bicycle accident Crush injury Does not include simple rear-end MVC without above criteria Any injury causing functional impairment Exhibit SE7.c